Medical Billing and Coding

• Independently perform complex, specialty-specific professional fee coding (CPT/HCPCS and ICD-10-CM) for physician services rendered in both office and hospital settings
• Ensure all coding adheres strictly to official guidelines (e.g., provided by AAPC or AHIMA), federal regulations (CMS), and organizational compliance standards
• Identify the need for formal clinical queries for documentation clarification when necessary for professional or facility records
• Maintain high accuracy and productivity standards appropriate to the complexity of the assigned workload
• May provide informal guidance to new coding staff on professional coding nuances

Coder II – Cardiology

• Identify opportunities to improve provider documentation and create an education plan tailored to each assigned provider
• Arrange educational sessions with assigned providers aimed at quality of care and documentation improvements
• Prepare comprehensive reports and presentations on coding quality trends, risk areas, and educational outcomes using data visualization techniques
• Provider onsite education, based on business needs
• Collaboration with other market provider facing role
• Use data analytics tools to assess coding quality, identify error patterns, and monitor compliance with internal and external standards
• Analyze coding audit results and other relevant data to develop data-driven educational materials and interventions
• Participate in cross-functional teams to improve documentation, data integrity, and workflow processes

Medical Coder

• Independently perform complex, specialty-specific professional fee coding (CPT/HCPCS and ICD-10-CM) for physician services rendered in both office and hospital settings, ensuring expert application of modifiers and E/M guidelines
• Perform entry-level facility coding for simple outpatient encounters (e.g., diagnostic imaging, labs) and basic inpatient services (e.g., uncomplicated admissions, short stays) using ICD-10-CM and ICD-10-PCS, where applicable
• Ensure all coding adheres strictly to official guidelines (e.g., provided by AAPC or AHIMA), federal regulations (CMS), and organizational compliance standards
• Identify the need for formal clinical queries for documentation clarification when necessary for professional or facility records
• Maintain high accuracy and productivity standards appropriate to the complexity of the assigned workload
• May provide informal guidance to new coding staff on professional coding nuances

Coder II – ENT, Audiology

• Responsible for abstracting and validating CPT, ICD-10 and HCPCS codes for inpatient, outpatient and physician's office/clinic settings.
• Adheres to all coding and compliance guidelines.
• Maintains knowledge of coding/billing updates and payer specific coding guidelines.
• Serves as a subject matter expert for assigned specialty.
• Abstracts/codes for assigned provider(s)/division(s) based on medical record documentation.
• Utilizes appropriate coding software and coding resources in order to determine correct codes.
• Communicates billing related issues to assigned supervisor/manager and participates in meetings in order to improve overall billing, when applicable.
• Follows departmental policies for charge corrections.
• Participates in coding educational opportunities (webinars, in house training, etc.).
• Provides feedback to providers in order to clarify and resolve coding concerns.
• Resolves assigned pre-billing edits.
• Assists in identifying areas that require additional training.
• Mentors and assists in training other coders and new team members.

Ambulatory Coder III, ENT

• Responsible for validating/reviewing and assigning applicable CPT, ICD-10, Modifiers and HCPCS codes for inpatient, outpatient and physicians office/clinic settings.
• Adheres to all coding and compliance guidelines.
• Maintains knowledge of coding/billing updates and payer specific coding guidelines for multi-specialty medical practice(s).
• Communicates with providers and team members regarding coding issues.

Ambulatory Coder II, Professional Billing

• Responsible for abstracting and validating CPT, ICD-10 and HCPCS codes
• Adheres to all coding and compliance guidelines
• Maintains knowledge of coding/billing updates and payer specific coding guidelines
• Communicates billing related issues to assigned supervisor/manager
• Participates in coding educational opportunities
• Provides feedback to providers to clarify and resolve coding concerns
• Resolves assigned pre-billing edits
• Assists in identifying areas that require additional training
• Mentors and assists in training other coders and new team members

Ambulatory Coder II, Ortho

• Responsible for abstracting and validating CPT, ICD-10 and HCPCS codes for inpatient, outpatient and physician's office/clinic settings
• Adheres to all coding and compliance guidelines
• Maintains knowledge of coding/billing updates and payer specific coding guidelines
• Serves as a subject matter expert for assigned specialty
• Communicates billing related issues to assigned supervisor/manager
• Participates in coding educational opportunities (webinars, in house training, etc.)
• Provides feedback to providers in order to clarify and resolve coding concerns
• Resolves assigned pre-billing edits
• Assists in identifying areas that require additional training
• Mentors and assists in training other coders and new team members

Ambulatory Coder III

• Codes medical information into the Prisma billing/abstracting systems using established professional and regulatory coding guidelines.
• Ensures that each diagnosis present on admission (POA) indicator is assigned appropriately.
• Codes for multiple facilities.
• Adheres to Prisma Health Coding and Compliance policies and procedures for assignment of complete, accurate, timely and consistent codes.
• Performs Inpatient coding including major traumas and Neonatal Intensive Care Unit (NICU) records by assigning International Classification of Diseases (ICD) and International Classification of Diseases-Procedure Coding System (ICD-PCS) codes as well as the Diagnosis Related Groups (DRG) assignment.
• Abstracts and assigns and verifies codes for Major Complications and Comorbidities/Complications and Comorbidities (MCC/CCs), Hospital-Acquired Condition/Patient Safety Indicator (HAC/PSI) and Quality Indicators capture as appropriate through documentation validation.
• Verifies assignment of DRGs, MCC/CCs, Hospital Acquired Conditions (HACs) and Patient Safety Indicators (PSIs) that most appropriately reflect documentation of the occurrence of events, severity of illness, and resources utilized during the inpatient encounter and in compliance with department policies and procedures.
• Selects the optimal principal diagnoses with appropriate POA indicator assignment and sequencing of risk adjustment diagnoses following established guidelines.
• Reviews work queues to identify charts that need to be coded and prioritizes as per department-specific guidelines and within designated timelines.
• Follows up on On-hold accounts daily for final coding.
• Identifies and requests physician queries following established guidelines when existing documentation is unclear or ambiguous following American Health Information Management (AHIMA) guidelines and established organization policies.
• Ensures all open queries initiated by Clinical Documentation Specialists have been addressed prior to final coding.
• Adheres to department standards for productivity and accuracy.
• Identifies and trends coding issues escalating identified concerns.
• Consults, provides professional expertise to and collaborates with clinical documentation specialists on coding and documentation practices and standards.

Health Information Management Inpatient Coder

• Assigns appropriate ICD and CPT codes for reimbursement and statistical purposes.
• Follows ICD, CPT, CMS, and other regulatory coding guidelines.
• Abstracts clinical information from medical records for complete and accurate statistical documentation.
• Reviews and interprets medical documentation to accurately assign ICD and CPT codes for facility or professional reimbursement and statistical purposes.
• Abstracts information into computer for reimbursement and statistical purposes.
• Researches and stays current with trends in healthcare coding and compliance.
• Keeps department manager up to date with any coding or documentation issues.
• Works as a team with physicians, coding staff and other hospital personnel to ensure proper and accurate code assignment and continuous quality improvement.
• Responsible for assisting with coding claim edits and reviewing claim denials for correction.
• Reports to work in a timely manner and adheres to attendance policies.
• Conscientious of scheduling time off in advance so as not to interfere dramatically with coding turnaround times.
• Performs all Other duties as assigned.

Professional Medical Coder II

• Assigns appropriate ICD and CPT codes for reimbursement and statistical purposes.
• Follows ICD, CPT, CMS, and other regulatory coding guidelines.
• Abstracts clinical information from medical records for complete and accurate statistical documentation.
• Reviews and interprets medical documentation to accurately assign ICD and CPT codes for facility or professional reimbursement and statistical purposes.
• Abstracts information into computer for reimbursement and statistical purposes.
• Researches and stays current with trends in healthcare coding and compliance.
• Keeps department manager up to date with any coding or documentation issues.
• Must work independently and collaboratively to support the achievement of department People, Quality, Finance, and Service goals as well as organizational goals.
• Works as a team with physicians, coding staff and other hospital personnel to ensure proper and accurate code assignment and continuous quality improvement.
• Responsible for assisting with coding claim edits and reviewing claim denials for correction.
• Reports to work in a timely manner and adheres to attendance policies.
• Conscientious of scheduling time off in advance so as not to interfere dramatically with coding turnaround times.
• Performs all other duties as assigned.

Vascular Medical Coder

• Ability to comprehend medical record documentation to accurately assign codes for both concurrent and discharged accounts across multiple specialties.
• Meets minimum requirements for production and quality monthly.
• Requires a working knowledge of code sequencing for grouper-related payers with attention to detail to avoid rework and waste with charge capture assessment component.
• Requires understanding and application of M.E.A.T. criteria (i.e., monitoring, evaluation, assessment, treatment) using ICD 10 CM transaction data set to capture diagnoses.
• Analyzes high-risk encounters for accurate and/or missing charges gaps prior to encounter completion (i.e., missing charges from anesthesia, surgery) when manual charge capture occurs.
• Understand complexity of billing requirements and incorporates payer specific trends into day-to-day reviews to reduce “take backs” associated with un-clear, or un-substantiated care rendered.
• Requires excellent coding knowledge of ICD 10 CM, CPT 4, and modifier application, with expectations to maintain certification (i.e., CCS, CPC, RHIT, or RHIA) and apply ICD 10 CM Coding Guidelines specific to both inpatient and outpatient encounters.
• Facilitate modifications to clinical documentation through query interaction to ensure that the information captured supports the level of service rendered, with attention towards chronic conditions, hierarchical condition categories (HCC), and risk adjustment factors (RAF).

Inpatient Coder

• Responsible for assisting the coding department with the day-to-day non-coding duties support activities
• Assigns codes to office-based visits and procedures using the International Classification of Diseases (ICD-10-CM), Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS)
• Resolve coding edits to assure accurate and complete claims submission
• Sequences diagnoses and procedure codes as outlined in CPT, ICD-10-CM, and HCPCS Coding Guidelines while adhering to local and national governmental payer guidelines
• Reviews all clinician documentation to support assigned codes in the health information record
• Follows up and obtains clarification of inaccurate documentation as appropriate
• Codes risk adjustable encounters, resolves CRMs, and trends coding denials, as assigned
• Conducts formal coding and documentation reviews, clinician reviews and quality reviews, as assigned
• Assists with coding research functions and education activities
• Creates clinician coding and documentation education based on query trends or ad-hoc requests
• Adheres to the organization and departmental guidelines, policies, and protocols.
• Abides by Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines.
• Practices ethical judgment in assigning and sequencing codes for proper insurance reimbursement
• Maintains confidentiality of patient.

Physician Support Coder

• Code medical records utilizing ICD-10-CM and CPT-4 coding conventions.
• Review the medical record to ensure specificity of diagnoses, procedures and appropriate/optimal reimbursement for hospital and/or professional charges.
• Review complex medical records and accurately code primary/secondary diagnoses and procedures using ICD-10-CM and/or CPT coding conventions.
• Coordinate/review the work of designated employees.
• Ensure quality through regular audits.
• Consult and educate physicians on coding practices.

Medical Records Coder II

• Ability to comprehend medical record documentation to accurately assign codes for both concurrent and discharged accounts across multiple specialties.
• Meets minimum requirements for production and quality monthly.
• Requires a working knowledge of code sequencing for grouper-related payers with attention to detail to avoid rework and waste with charge capture assessment component.
• Requires understanding and application of M.E.A.T. criteria (i.e., monitoring, evaluation, assessment, treatment) using ICD 10 CM transaction data set to capture diagnoses.
• Analyzes high-risk encounters for accurate and/or missing charges gaps prior to encounter completion (i.e., missing charges from anesthesia, surgery) when manual charge capture occurs.
• Understand complexity of billing requirements and incorporates payer specific trends into day-to-day reviews to reduce “take backs” associated with un-clear, or un-substantiated care rendered. (i.e., varying modifier assignment for EAPG vs. Non-EAPG payer specificity)
• Requires excellent coding knowledge of ICD 10 CM, CPT 4, and modifier application, with expectations to maintain certification (i.e., CCS, CPC, RHIT, or RHIA) and apply ICD 10 CM Coding Guidelines specific to both inpatient and outpatient encounters.
• Facilitate modifications to clinical documentation through query interaction to ensure that the information captured supports the level of service rendered, with attention towards chronic conditions, hierarchical condition categories (HCC), and risk adjustment factors (RAF).
• Demonstrates an excellent working knowledge of hospital information systems to retrieve data specific information (i.e., order diagnosis, patient type) within a complicated filing schema including non-hospital data (i.e., Media Tab, Office Visits etc)

Facility ED Coder

• identify opportunities to improve provider documentation and creates an education plan tailored to each assigned provider
• report to the Manager, Medicare Risk Adjustment
• arrange educational sessions with assigned providers aimed at quality of care and documentation improvements
• identify educational needs based on reports
• prepare comprehensive reports and presentations on coding quality trends, risk areas, and educational outcomes using data visualization techniques
• provider onsite education, based on business needs
• collaboration with other market provider facing role
• use data analytics tools to assess coding quality, identify error patterns, and monitor compliance with internal and external standards
• analyze coding audit results and other relevant data to develop data-driven educational materials and interventions
• participate in cross-functional teams to improve documentation, data integrity, and workflow processes

Medical Coding Educator

• Evaluate medical records and provide clinical and surgical abstraction
• Accurately code diagnostic and procedural information
• Consult with medical providers for record clarification
• Ensure compliance with coding rules and regulations
• Compile reports and tabulate data from medical records
• Identify validation edits and ensure accurate coding
• Work independently under regular supervision

Complex Coder, Surgical Cardiology

• Responsible for abstracting and validating CPT, ICD-10 and HCPCS codes for inpatient, outpatient and physician's office/clinic settings.
• Adheres to all coding and compliance guidelines.
• Maintains knowledge of coding/billing updates and payer specific coding guidelines.
• Serves as a subject matter expert for assigned specialty.
• Abstracts/codes for assigned provider(s)/division(s) based on medical record documentation.
• Utilizes appropriate coding software and coding resources in order to determine correct codes.
• Communicates billing related issues to assigned supervisor/manager and participates in meetings in order to improve overall billing, when applicable.
• Follows departmental policies for charge corrections.
• Participates in coding educational opportunities (webinars, in house training, etc.).
• Provides feedback to providers in order to clarify and resolve coding concerns.
• Resolves assigned pre-billing edits.
• Assists in identifying areas that require additional training.
• Mentors and assists in training other coders and new team members
• Performs other duties as assigned.

Ambulatory Coder III, Ortho

• Monitor and collect Medicare Stars data to improve health plan ratings
• Conduct specific medical record reviews
• Analyze findings and make recommendations for corrective actions
• Prepare formal documentation for compliance with applicable standards
• Perform Health Plan Employer Data Information Set data collection (HEDIS) and National Committee for Quality Assurance (NCQA) accreditation activities

Medicare Risk Adjustment Coder

• Coordinate/review the work of subordinate employees and assist with the training and continuing education programs.
• Code medical records utilizing ICD-10-CM, ICD-10-PCS, and/or CPT-4 coding conventions.
• Review the medical record to ensure specificity of diagnoses, procedures and appropriate/optimal reimbursement for hospital and/or professional charges.
• Abstract information from medical records following established methods and procedures.
• Review the complex (problematic coding that needs research and reference checking) medical records and accurately code the primary/secondary diagnoses and procedures using ICD-10-CM, ICD-10-PCS and/or CPT coding conventions.
• Ensure quality and quantity of work performed through regular audits.
• Assist with research, development and presentation of continuing education programs on areas of specialization.
• Sequence the diagnoses and procedures using coding guidelines.
• Ensure DRG/APC assignment is accurate.
• Consult with and educate physicians on coding practices and conventions in order to provide detailed coding information.
• Communicate with nursing and ancillary services personnel for needed documentation for accurate coding.
• Maintain a thorough understanding of anatomy and physiology, medical terminology, disease processes and surgical techniques through participation in continuing education programs to effectively apply coding guidelines to inpatient and outpatient diagnoses and procedures.
• Maintain a thorough understanding of medical record practices, standards, regulations, Joint Commission on Accreditation of Health Organizations (JCAHO), Health Care/Finance Administration (HCFA), Medical Review of North Carolina (MRNC) etc.
• Assist with special projects as required.
• Perform other related duties incidental to the work described herein.

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